Word came last week about a new study published in the journal Neurorehabilitation and Neural Repair about the Alexander Technique and patients with Parkinson’s Disease.

Parkinson’s Disease is a progressive neurological condition affecting movement. Progressive in this sense means that symptoms worsens over time. The condition often begins with slight tremors and reduced facial expressions and may eventually lead to a stiffening and slowing of all movement. Parkinson’s is largely treated with medication, though Parkinson’s patients and their doctors often explore methods that can improve a patient’s quality of life while coping with the disease.

The Alexander Technique and Parkinson’s has been studied before. In 2002, a randomized control trial published in Clinical Rehabilitation assigned 98 Parkinson’s patients either to 24 individual Alexander Technique lessons, 24 individual massage sessions, or no intervention beyond their normal drug treatment. The study showed that Alexander lessons significantly increased the ability of patients to carry out everyday activities (there was no significant change in the massage group). The benefits remained when patients followed up 6 months after their lessons ended. The Parkinson’s patients who took Alexander Technique lessons also had less change in their Parkinson’s medication than either of the other groups (this is notable since medication dose usually increases with time as the disease worsens). The patients themselves reported improvements in balance, posture, walking, and increased coping with the disease and reduced stress.

One of the challenges in a randomized control trial like the 2002 study is to explain why a particular intervention is effective. In the 2002 study, massage was used to control for the effects of touch. Though massage and the Alexander Technique use touch quite differently, they use an equivalent amount of touch in a session. Since the Alexander Technique had a beneficial effect but massage did not, the researchers could conclude that touch alone wasn’t enough to benefit the Parkinson’s patients. The patients who took Alexander Technique lessons clearly learned something, but what?

Enter the most recent study: “Lighten Up: Specific Postural Instructions Affect Axial Rigidity and Step Initiation in Patients with Parkinson’s Disease,” by lead author, Dr Rajal Cohen. (You can read it in full here)

This was a smaller study and deceptively simple: 20 patients with mild to moderate Parkinson’s Disease practiced two contrasting postural instructions for all of ten minutes each. One set of instructions, called “Pull Up,” was based on effortful conceptions of posture. The other set of instructions, “Lighten Up,” were based on the Alexander Technique of releasing into length.

The research team then measured axial rigidity (increased axial rigidity interferes with movement), postural sway (sway can increase the risk of falling in Parkinson’s patients), and the smoothness and efficiency of initiating movement.

The study is fascinating to anyone who is interested in movement and posture because it shows that how we think about posture can make a measurable difference in the quality of our posture and movement.

During the study, the Parkinson’s patients read contrasting explanations for the two separate set of instructions. The “Pull Up” instructions were based on familiar conceptions of posture:

Parkinson’s makes you weaker, so it is important to activate your core muscles to pull yourself up to your full height. For the next few minutes I would like you to focus on feeling your neck and trunk muscles work strongly to pull you up.

The patients then practiced these specific “Pull Up” instructions (which might be familiar to anyone who has worked with either a personal trainer or a drill sergeant):

Use your core muscles to pull yourself up to your fullest height; engage the muscles in your abdomen and lower back; feel your neck and trunk muscles working to pull you up; pull your stomach in, your head and chest up, and your shoulders back.

“Lighten Up” instructions were based on the Alexander Technique. The researchers had the subjects read this explanation:

Whatever our condition, we make matters worse by pulling ourselves down, and especially by tightening the neck and pulling the head down. For the next few minutes I would like you to focus on allowing an upward direction.

Then the patients practiced the following instruction:

Notice that you are pulling yourself down and give yourself permission to stop doing it; let your head balance easily at the top of your spine; allow your spine to be uncompressed and your torso to open effortlessly; let your shoulders and chest be open and light.

As a control, the researchers had the patients practice a “relaxed” condition:

Imagine that it is the end of a long day and you feel tired and lazy; allow your head to feel heavy and sink slightly forward and down; relax your shoulders and allow them to hang heavily.

The researchers varied the order in which the patients practiced “Pull Up,” “Lighten Up,” and “Relaxed,” to control for possible carryover effects from the different instructions. What did they find? When patients practiced “Lighten Up,” they showed less axial rigidity, less postural sway, and increased smoothness of initiating movement than when they practiced “Pull Up” or “Relaxed.”

There are a couple of surprising things about these results. The authors note that since Parkinson’s Disease has such a detrimental effect on motor control, they did not expect the patients to show a measurable difference when practicing something so subtle as differing postural intentions. Most remarkable to me is that such brief instructions, given without the hands-on guidance found in a traditional Alexander lesson, would have a beneficial result. The study gives some inkling of why a course of lessons—like the 24 lessons in the 2002 study of Parkinson’s patients—might be so positive.

One of the things that excites me about this study is the way in which it clearly articulates the difference between how Alexander Technique teachers approach posture—lightening up to make things easier—versus more familiar approaches to posture—pulling up to make you stronger. We Alexander teachers often feel like we are in danger of getting swept away in the great wave of “core conditioning,” struggling to prove the benefits of a gentler approach to movement than “power through” and “no pain no gain.” If this study can help convince people that lightening into length has proven benefits, it might help not only Parkinson’s patients, but anyone who wants to move more easily and effectively.

Recently my Facebook feed has blown up with articles and news segments about the dangers of “text neck.” It turns out that spending hours a day hunched over your smartphone texting is a bad idea and leads to all sorts of neck and upper back issues. Who knew? The news stories have given some good counsel—like limiting the amount of time you spend on your phone and moving your body in ways that are different than hunching over a phone. But as I’ve read the advice about preventing “text neck,” I keep wondering, do we give ourselves any choice in the matter?

I was reminded of a student who came to me for Alexander Technique lessons several years ago, just before the smartphone revolution. He was a doctor complaining of neck pain. He tried to set up regular lessons, but like many doctors, his schedule was not entirely his own. Even when we managed consistent lessons, he was always on call. With most of my students, I ask that they leave their phones off so that we can work without interruption. But he had to leave his pager on, just in case he had to respond to an emergency at the hospital.

I have to admit, he was a challenging student. At the start of each lesson, he would fill me in with a detailed report on his neck symptoms at work. He monitored himself ceaselessly to see if there was any improvement. He was obsessed with finding the “correct way to move” and gave himself detailed instructions using his voluminous knowledge of human anatomy. He would inform me, “I need to tone up through the erector spinae group, widen through the trapezius and release into the quads.” I suggested that he not micro-manage his movements, and told him the parable of the centipede who tried to control all one hundred legs consciously and ceased to be able to walk at all. I tried to convince him that the first step was to leave himself alone. He needed to practice “non-doing:” it would give him a chance to observe himself and see if he could discover if his movement habits contributed to his neck problem.

One lesson I finally succeeded in getting him to stand quietly, leaving himself alone. I had just placed my hand where his head meets his neck and was helping him experience a “free neck”—moving his head gently back and forth in the “no” direction—when his pager went off. At the sound of the buzzing, his neck tensed dramatically, the back of his head pulled back, and his shoulders went up around his ears.

He duly checked his pager—it was not an emergency. We looked at each other. “I think we know why you have some neck tension,” I said.

‘Push notifications’ inform us not only of texts or phone calls, they alert us to e-mail, Facebook status updates, tweets, breaking news, traffic reports, weather alerts, and the latest available level on Angry Birds Star Wars II. Our response becomes habitual. The alert sounds and we jump into action. If that habit includes pushing our head forward 30 degrees, we may not even notice our necks tense to carry the 40 lbs of functional weight. That’s the thing about habits: they are unconscious and automatic.

The head is a heavy object. The average head weighs about 10 pounds. When your neck is free and the head is poised on a lengthening spine, it has a functional weight of 10 pounds. But for every degree the head is held forward—whether towards a cell phone, a computer, a book, a music stand, or a musical instrument—its functional weight increases dramatically. As this study by Kenneth K. Hansraj found, a 10 pound head held 30 degrees forward has a functional weight of 40 pounds.

So what we do with our heads has an enormous impact on the health of our necks, shoulders and backs. With my doctor student, the anxiety around the insistent and unbidden summons of his pager caused a spasm of tension in his neck, jerking his head back into his spine. The action was particularly dramatic in his Alexander lesson because it happened right after I had helped him find length in the neck and freedom at the head-neck joints. In his everyday life, though, he rarely freed his neck and it became increasingly tense and painful throughout the week.

Smartphones and doctors' pagers are similar in one important respect: they are stimulus response-machines. And smart phones are even more stimulating: "push notifications” inform us not only of texts or phone calls, they alert us to e-mail, Facebook status updates, tweets, breaking news, traffic reports, weather alerts, and the latest available level on Angry Birds Star Wars II. Our response becomes habitual. The alert sounds and we jump into action. If that habit includes pushing our head forward 30 degrees, we may not even notice our necks tense to carry the 40 lbs of functional weight. That’s the thing about habits: they are unconscious and automatic.

But there’s a key difference between doctors' pagers and our smartphones. Doctors are required to have a pager and may even, like my former student, resent its constant thrall. But if you’re anything like me, you love your smartphone. In fact, you could say that the stimulus from within—”I wonder what my friends think of that cat photo I just posted on Facebook,” for example—is as strong as the push notification from without.

Understanding the power of habit is as important in preventing “text neck” as limiting our time on our phones—maybe more so, since so many of us enjoy the time we spend on our phones and don't have any intention of reducing it down. With my doctor student, we practiced a different response to his pager: when it sounded, he would remind himself to pause, take his time in responding, free his neck. We can do the same thing with our phones. The next time in pings, we can give our necks a break. We can take a moment, however fleeting, and do nothing.

I’ve been writing this week about how music teachers can help their students find poise without resorting to nagging them about their posture. Music teachers often bring a great deal of ingenuity to teaching technique and musicianship, but then resort to simple exhortations like “sit up straight” or “stand tall” when teaching poise. From my work as an Alexander Technique teacher, I’ve learned that poise is a subject just as worthy of creative study as, say, vibrato in string technique.

As much as I enjoy giving this advice, it's a little unfair. After all, music teachers don’t teach in a vacuum. If their students show up distractible, tired and slouching to their lessons, it’s not the fault of their music teacher. Their students could just be sitting all day in school.

Two recent posts brought home to me the extent of the challenge. The first was a piece in the Washington Post by Angela Hanson, a pediatric occupational therapist. She wrote about her work with children with attentional issues in school. She argues that children require a minimum of outdoor play—unencumbered movement—in order to develop attentional control.

She describes working with a 6 year-old boy who was struggling to connect with his peers and pay attention in school. He attended her TimberNook camp over the summer, which gives children a week of immersion in the woods.

In the beginning of the week, he consistently pursued total control over his play experiences with peers. He was also very anxious about trying new things, had trouble playing independently, and had multiple sensory issues.

Amazingly, by the end of the week, he started to let go of this need to control all social situations. He also started tolerating and asking to go barefoot, made new friends, and became less anxious with new experiences. The changes were really quite remarkable. All he needed was time and practice to play with peers in the woods—in order to foster his emotional, physical, and social development.

When Hanson met with the boy’s teachers at the start of the fall, she told them that he needed an hour of recess a day at minimum. The teachers were sympathetic, but they told her that the maximum they could do was 15 minutes a day. Curricular demands—especially preparing for standardized tests—made that amount of recess time impossible. For a 6 year-old.

The second piece was published on Grant Wiggins’ blog. An anonymous teacher wrote about her experience shadowing two students at her high school—first a 10th grade student and then a 12th grade student. This was her first takeaway after two days of being a student at her high school:

Students sit all day, and sitting is exhausting.

I could not believe how tired I was after the first day... In every class for four long blocks, the expectation was for us to come in, take our seats, and sit down for the duration of the time. By the end of the day, I could not stop yawning and I was desperate to move or stretch. I couldn’t believe how alert my host student was, because it took a lot of conscious effort for me not to get up and start doing jumping jacks in the middle of Science just to keep my mind and body from slipping into oblivion after so many hours of sitting passively.

I was drained, and not in a good, long, productive-day kind of way. No, it was that icky, lethargic tired feeling. I had planned to go back to my office and jot down some initial notes on the day, but I was so drained I couldn’t do anything that involved mental effort (so instead I watched TV) and I was in bed by 8:30.

Of course, we know that students sit all day and that sitting is tiring, but after years of standing in front of a class—lecturing, able to move around—this teacher had forgotten. And lest we put all the blame on American public schools, this teacher taught at a private school overseas.

In case these two pieces don’t depress you enough, what does sitting all day do to the back? The old adage, “If you don’t use it, you lose it,” applies to the coordination of the back as much as anything. Sitting weakens the back. The c-curve slump that chairs and desks encourage becomes locked into place, as connective tissue hardens to support the collapsed posture. Many students appear to grow into their chairs: you can still see the shape of the chair in their back when they stand up. After years of sitting, they can’t “sit up straight,” even if saying “sit up straight” was good advice. Their backs are no longer responsive to the command.

Yesterday, I wrote about Kyra teaching a cello lesson to a five year-old. She found a creative way to help her student find poise without saying, “sit up straight!” As I wrote at the end of the post, one of the reasons that her strategy worked was that she was teaching a very young child, who still retained a lot of mobility. She might not have had the same luck teaching an older student. In my Alexander practice, I find that it takes several lessons before teenage and college students—as young as they are—start to rediscover the coordination of their backs.

The regimented sedentariness of many schools is a huge problem. It impacts student learning, creativity and health. Because of this, Alexander Technique and music teachers are natural allies. They can team up to bring more rhyme and reason—not to mention movement and poise—to how we teach our children, both in school and out.

On Wednesdays, Kyra teaches the cello to an adorable five year-old, "E." In her lesson yesterday, E was sitting slumped on her little green stool, hanging backward off her cello. Instead of telling her to “sit up straight,” Kyra asked E to touch her cello bridge with her left hand.

When E reached for her bridge, her back lengthened and she sat up. Funnily enough, she didn’t really notice the change. She just sat poised and alert for the rest of her lesson.

It was a small moment, but a great example of helping a child find poise at their instrument without nagging about posture.

Poise is important at any instrument. From a place of equilibrium you can move in any direction. Cellos are large instruments, even those made for five year olds, and it’s tempting for children to practice hanging off of them backwards or draping themselves over the front. It’s not surprising that teachers and parents want to discourage them from developing these habits. So why is telling children to “sit up straight” not the best idea?

It can be hard to tell the difference between poise and rigidity. Children told to “sit up straight” often hyperextend their lower backs. Over-tensing the back may look better than slouching, at least from a distance, but it is just as bad for the health of the back in the long run.

Also, “sit up straight” puts the focus on appearance rather than the experience of playing and risks making children self-conscious. True poise is inherently enjoyable, not because it looks good, but because it makes things easier.

And when you tell a child to “sit up straight,” you unwittingly create two acts: 1) sitting up straight and 2) playing the instrument. True ease comes when the whole body is in service to the task at hand. Playing becomes one act, supported by the whole body.

When Kyra asked E to touch her cello bridge, E reached with her hand and her body automatically supported the action. The same can be true of the more specialized movements of playing the cello.

Coming up with alternatives to "sit up straight" requires creativity and experimentation, especially since children change so much as they age. After Kyra told me about E’s lesson, she laughed, saying that in reality, E could have easily stayed slumped and still reached the bridge with her hand. But she lucked out—maybe because E is still so young and her body is responsive and ready to move. Kyra figures that the same instruction might not work next week, but by then, she’ll think of something else!